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31B-009 (4) r Young Roofing Co., Inc. . Date:December 8, 2015 14A.Texas Rd, To: Nate Korza 110 Prospect St. Northampton,MA,01060 Northampron,MA. 01060 I PO.Box 60056 Job Location: Flo,ence.MA 01067 413-584.1367 Specifications: 413-586-9167 1. Install 1/2 inch nailer to all roof edges. a13.s31•seal - 413-585-0226 2. Install 1/2 inch Secure-shield polyisocyanurate insulation to the complete roof ( pgtQQACket:= area. (Approx.650 sf) 3KVUO&Qct,�lseCSOra LicNo.-011878 3. Install Carlisle's .060 reinforced EPDM mechanically attached roofing system. 4. Fabricate and install .032 gauge white aluminum edge metal. 5. Flash chimney, pipe,and vent with a Manufacture approved detail. 6. Remove all our roof mg debris f°om the job site and dispose of. All materials guaranteed to be as specified.Any alterations or deviation AUTHORIZED SIGNATURE: RICHARD YOUNG. PRESICtNT from above specifications involving extra cost will be executed only upon wntten orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays Acceptance of proposal The above specifications and beyond our control.Owner to carry fire and other necessary insurance. conditions are satisfactory and are hereby accepted.You are All accounts not paid within 30 days are subject to a lace charge of I authorized to do the work specified. Payment will be made as 1!2%per month on the unpaid balance. In the event chat legal action is outlined above. instituted to collect any sums due under this agreement.the undersigned agrees to pay all cost incurred including reasonable attorney's fees. SIGNATURE '-"---^-'" " DATE OF ACCEPTANCE____ i i i i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 �tw Boston,MA 02114-2017 v' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): 0 6 Address: 'P-0 , (�0x (:Cook IOY'L�tN,Q�� lu! I� DID(o� City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 0 4. ® I am a general contractor and I 6 ®New construction employees (full and/or part-time).* have hired the sub-contractors 2.® I am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling ship and have no employees These sub-contractors have g, ® Demolition working for me in any capacity. employees and have workers' 9. ® Building addition [No workers' comp. insurance comp. insurance.• required.] 5. ® We are a corporation and its 10.® Electrical repairs or additions 3.® I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.® Roof repairs insurance required.] + c. 152, §1(4),and we have no employees. [No workers' 13.®Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �� S\4 yaV1 co Policy#or Self-ins. Lie. #: 61-P f f=✓c, b `l 0—M 1w Expiration Date: Job Site Address: �1 Yr�'SY�' City/State/Zip: looa lu�p� ' /I14 "p(oo Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde�hhe pai and enalties of perjury that the information provided aboveis true and correct. Si nature: l Date: )d-)q 16 Phone#• 35L03(Q-7 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i I l� l I 1 I i .,� SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9. Realstered Home Improvement Co tractor: 1V to YOV7 Not Applicable ❑ boy i 101�a3 Company Name Registration Number Address Expiration Date Telephone 4)3- i`/ 03 7 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... 14 11. - Home Owner Exemption The current exemption for"homeowners" was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 10835.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature i I i i i i ', i j i i SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) EJ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs E]] Decks [❑ Siding M] Other[E] Brief Description of Proposed Sae cAA6,Ck'J_ PAUVtf,- . Work: Alteration of existing bedroom Yes -X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes >( No Plans Attached Roll -Sheet sa. If New house and or addition to existing housing, complete the following: a. Use of building : One Family x Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date �j , as Owner/Authorized Agent hereby declare that the statements d information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and pe alties of perjury. Print Name Signature of Owner/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW ® YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW ® YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. t. 'I I I I i ,�.. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability s Room 100 Water/Well Availability ° orthampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 1 l 0 Pr(JsrP j S�-' Map Lot Unit N O r)/„A A�&� M-k. Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 9444 no Name(Print) Current Mailing Address: Telephone 41,13 ,3 - 1567 Signature 2.2 Authorized Agent: R �.U: ►3 U� �on�� IU������� d I(��� Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building n�r� I 1 (a) Building Permit Fee 2. Electrical I� "I 1 (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2+3+4+5) 00 ! Check Number This Section For Official Use Only Building Permit Number: IIsssued: Signature: Building Commissioner/Inspector of Buildings Date i I i i 110 PROSPECT ST BP-2016-0773 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B-009 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2016-0773 Project# JS-2016-001306 Est. Cost: $4000.00 1 ee: x40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: YOUNG ROOFING CO INC 011878 Lot Size(sq. ft.): 8973.36 Owner: KORZA NATHAN Zoning. URC(100)/ Applicant: YOUNG ROOFING CO INC AT. 110 PROSPECT ST Applicant Address: Phone: Insurance: P O Box 60056 (413) 584-1367 WC FLORENCEMA01062 ISSUED ON:121912015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL NEW ROOF SYS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType• Date Paid: Amount: Building 12/9/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner